Received: 12 February 2019 Revised: 9 July 2019 Accepted: 16 July 2019

DOI: 10.1111/cid.12836

ORIGINAL ARTICLE

Influence of implant macrodesign and insertion connection

technology on the accuracy of static computer-assisted
implant surgery

Karim El Kholy Dr. Med. Dent., MS, DMSc, FRCD(C)1,2 | Supriya Ebenezer BDS, MDS1 |
Julia-Gabriela Wittneben PD, Dr. Med. Dent., MMSc3 | Rafael Lazarin DDS, MS1 |
Dominique Rousson DDS4 | Daniel Buser Dr. Med. Dent1

1
Department of Oral Surgery and
Stomatology, School of Dental Medicine,
University of Bern, Bern, Switzerland
2
Division of Periodontology, School of Dental
Medicine, Harvard University, Boston,
Massachusetts
3
Department of Reconstructive Dentistry and
Gerodontology, School of Dental Medicine,
University of Bern, Bern, Switzerland
4
Division of Implants and Regenerative
Medicine, Harvard School of Dental Medicine,
Boston, Massachusetts
Correspondence
Karim El Kholy, Department of Oral Surgery
and Stomatology, School of Dental Medicine,
University of Bern, Freiburgstrasse
7, Bern 3012, Switzerland.
Email: karim_elkholy@hsdm.harvard.edu
Abstract
Objective: The aim of this study was to evaluate the effect of three different
macrodesigns and two different insertion devices on the accuracy of static
computer-assisted implant surgery (sCAIS).
Materials and Methods: Ninety implant replicas with three different macrodesigns:
Soft tissue level (TL), bone level (BL), and bone level tapered (BLT) were placed in
30 dental models with two implant insertion devices: Guided adapter and guided
screwed-in mount. Preoperative and postoperative positions of implants were com-
pared and the mean angular deviation, crestal, and apical three-dimensional
(3D) deviation were calculated for each implant macrodesign and each insertion device.
Data were analyzed using analysis of variance, post hoc t-tests and Bonferroni-Holm's
adjustment method. P values less than .05 were considered statistically significant.
Results: BLT implants had lower mean 3D deviation values at the crest and the apex
when compared with 3D deviations with BL and TL implants (P < .05). Also, BLT
implants had lower angular deviations, when compared with BL and TL Implants,
however, angular deviations were not statistically significant (P > .05). Considering
the insertion device method, no significant differences were noted between insertion
devices irrespective of the deviation analyzed.
Conclusion: The macrodesign of dental implants may have an influence on the accu-
racy of sCAIS, with tapered designs offering slightly better positional accuracy than
parallel-walled macrodesigns independent on the method of insertion used.

KEYWORDS
accuracy, computer-aided, computer-assisted, digital, guided surgery, implant, implant design,
implant surgery, implantology

1 | I N T RO D UC T I O N efficiency.1 Digital technology in the field of implantology has

increased the use of computer-assisted implant surgery (CAIS). With
Benefits of digital workflow in dental medicine today are associated the use of this technology, clinicians are aiming for increasingly opti-
with high precision, simplification of fabrication procedures, and cost- mal results by positioning implants in the desired prosthetic and

Clin Implant Dent Relat Res. 2019;1–7. wileyonlinelibrary.com/journal/cid © 2019 Wiley Periodicals, Inc. 1
2 EL KHOLY ET AL.
anatomical position.2-5 Additionally, CAIS aids in fulfilling patients'
increasing demand for improved esthetics in combination with less
invasive procedures, producing minimal intrasurgical and postsurgical
discomfort. CAIS can be executed either using static or dynamic surgi-
cal guides. Static CAIS (sCAIS) surgery is performed using a surgical
template to transfer the virtual implant position from the treatment-
4
planning software to the surgical site. The use of sCAIS provides the
operator with more control and precision during osteotomy drilling and
implant placement, when compared to nonguided implant surgery.2,3
Although expectations of efficacy and predictability have increased, the
risk of inaccuracies resulting from different variables, generated during
the various steps involved still remains considerable.6-8 The accuracy of
sCAIS is defined as the deviation between the planned and the actual
position of an implant.9 This deviation can be a result of multiple
sources: from the imaging process, data transfer, template manufacture,
inaccurate positioning of the guide in the mouth, and drill errors.10,11
These variables may influence the angulation, length, and diameter of
the osteotomy as well as implant insertion that translates to deviations
in implant position.12-17
A meta-analysis focusing on trials with patients, by Tahmaseb
et al,18 concluded that the accuracy of sCAIS is within the clinically
acceptable range in the majority of the cases, however, a safety mar-
gin of at least 2 mm should be respected. Inaccurate implant position-
ing can directly compromise the final prosthetic outcome and safety
of the surgical procedure.
Currently, sCAIS is applicable for use with several implant systems,
in the form of partially or fully guided procedures, as deemed needed
by the clinician. Partially guided systems allow only guided osteotomy,
while fully guided systems ensure guided osteotomy and guided
placement. Several authors recommend fully guided sCAIS procedure
to improve accuracy of the final implant position.3,10,19,20 Several
studies compared different implant systems and planning systems
to identify deviations in actual and planned positions
implants.6,9,12,14,21 However, no study provides a comparative evalua-
tion of implant macrodesign as a determinant for accuracy in position.
The aim of the investigation was to evaluate the accuracy
achieved while placing implants with three different macrodesigns
and two different sCAIS insertion devices.
FIGURE 1 Model design and guide design used in the investigation
2 | MATERIALS AND METHODS
This study was conducted using 30 duplicate acrylic models
(BoneModels, Castellón de la Plana, Spain) simulating human bone with
three selected sites for implant placement corresponding to FDI posi-
tions 15, 12, and 23 in each model (Figure 1). Study casts were scanned
using an intraoral scanner (3Shape TRIOS 3; 3ShapeA/S, Copenhagen,
Denmark) and a cone-beam computed tomography (3D Accuitomo 170;
J. Morita Corp, Osaka, Japan) was taken. A digital wax-up of the missing
teeth was created using treatment planning software (DWOS, Den-
talWings, Inc, Montreal, Canada). All three digitally generated data sets
were then imported into the same software and the implants were
planned in the optimum three-dimensional (3D) prosthetic position. One
investigator (K.E.K.) performed all virtual planning. Surgical guides were
designed and exported from the virtual planning and then 3D printed
using a Rapidshape P30 printer (Rapid Shape GmbH, Heimsheim, Ger-
many). All guides were produced using SHERAprint-sg transparent resin
(SHERA Werkstoff-Technologie GmbH & Co KG, Lemförde, Germany).
Material thickness was set to 3 mm and the “guide-to-teeth offset” value
to 0.15 mm. Each operator visually checked guides for fit. Minor adjust-
ments were permitted, to the outer surface, in order to ensure full access
of the surgical handpiece but not to the inner surface of the guide.
2.1 | Implant placement
Ninety implant replicas with three different macrodesigns and two
implant insertion devices were equally distributed to different sites
for guided implant placement protocols.
The implant macrodesigns assessed were (Figure 2):
1. Thirty soft tissue level, standard plus implants (TL; Institut Straumann
of AG, Basel, Switzerland) featuring a parallel walled, non-self tapping
design with an endosseous portion of 10 mm length. All implants
used were 4.1 mm in diameter with a 1.8 mm machined collar.
2. Thirty bone level implants (BL; Institut Straumann AG, Basel, Swit-
zerland) featuring parallel walled, self-tapping design, with no
polished collar, 10 mm length, and 4.1 mm diameter.
EL KHOLY ET AL. 3

F I G U R E 2 Diagrammatic
representation of the implant
macrodesigns assessed. A, TL, BL, and
BLT implants entering the osteotomy.
Note that the BLT implant is guided by
the osteotomy walls only after the apical
portion has entered the osteotomy. B, TL,
BL, and BLT implants within the
osteotomy. TL, tissue level; BL, bone
level; BLT, bone level tapered

F I G U R E 3 Guided insertion devices. A, Guided portable adapter

(GPA) fitted onto the standard transfer piece. B, Guided screwed-in
mount (GSM) that fits into a handpiece adapter

F I G U R E 4 Diagrammatic representation of measurements of 3D

3. Thirty bone level tapered implants (BLT, Institut Strauman AG, Basel,
Switzerland), tapered design, self-tapping, self-cutting apical portion,
no polished collar, 10 mm in length, and 4.1 mm in diameter.
The insertion devices assessed were (Figure 3):
deviations, at crest and apex, as well as, angular deviations between
virtually planned and actual implant positions
1. Guided portable adapter (GPA) fitted onto a standard transfer
piece with a universal connection (Loxim; Institut Straumann AG,
Basel, Switzerland; Figure 3A)
4 EL KHOLY ET AL.

2. Handpiece adapter fitted onto a guided screwed-in mount (GSM;
Guided Transfer Piece, Institut Straumann AG, Basel, Switzerland;
Figure 3B).
A total of 30 fixtures of each implant design were equally placed
in three different sites. The selection of the insertion device was also
divided, ensuring that 15 models used the first insertion device (GPA)
and the other 15 used the second device (GSM). In each model, the
same insertion device was used for all three sites.
Two experienced operators (K.E. and R.L.) performed guided osteo-
tomy drilling and implant insertion procedures. Sequential drilling of all
osteotomies, according to manufacturer's recommendations for guided
surgery protocol corresponding to each macrodesign (Institut Straumann
AG, Basel, Switzerland), to receive one of the three different implant
designs was performed using standard sCAIS protocol. The implants were
then placed using a handpiece (Bien Air, Bienne, Switzerland) with the
respective implant insertion device through the surgical guide using a
speed of 30 rpm and a torque force of 35 Ncm. The placement was com-
pleted manually, when necessary, using a torque wrench and the assigned
insertion device, to the desired vertical position.
2.2 | Evaluation
Corresponding scan bodies were then hand tightened, and postopera-
tive digital impressions were taken using the intraoral scanner
previously mentioned. Standard tessellation language (STL) files were
then imported into the coDiagnostiX (DWOS) software containing the
previous digital plan. STL files containing virtually planned and actual
implant positions were superimposed using the same occlusal/incisal
landmarks as a reference. Treatment evaluation tool in the above-
mentioned software was used to measure angular and 3D deviations,
at crest and apex, between virtually planned and actual implant posi-
tions (Figure 4).
2.3 | Statistical analysis
The statistical analysis was performed with the software package R, Ver-
sion 3.5.1 (R Core Team 2013. R: A language and environment for statis-
tical computing. R Foundation for Statistical Computing, Vienna, Austria
(URL http://www.R-project.org). The effects of both the implant
macrodesign and the insertion method on three outcomes were ana-
lyzed with an analysis of variance after checking its assumptions such as
the normal distribution of the residuals. In case of significant effects, post
hoc t-tests were performed comparing every pair of levels of the signifi-
cant factor. Additionally, descriptive statistics as means, and standard
deviations were computed and box-plots were drawn illustrating signifi-
cant differences. P values less than .05 were considered statistically sig-
nificant. All P values of post hoc tests were corrected for multiple testing
using Bonferroni-Holm's adjustment method.

TABLE 1 ANOVA results showing effects of implant macrodesign, insertion device, and their combination

Factor Degrees of freedom Sum of squares Mean sum of squares F value P value
Angular deviation
Implant type 2 12.415 6.208 17.843 .426
Insertion method 1 2.601 2.601 7.476 .643
Interaction implant type: insertion method 2 1.353 0.677 1.945 .149
3D deviation at crest
Implant type 2 5.756 2.878 268.639 .017
Insertion method 1 0.171 0.171 15.999 .083
Interaction implant type: insertion method 2 0.406 0.203 18.956 .535
3D deviation at apex
Implant type 2 0.798 0.399 39.403 .033
Insertion method 1 0.004 0.004 0.4178 .104
Interaction Implant type: insertion method 2 0.000 0.000 0.0163 .981

Abbreviation: ANOVA, analysis of variance.

TABLE 2 Means for 3D and angular deviations of different implant macrodesigns and insertion devices

Implant macrodesign Insertion device 3D deviation at crest (mm) 3D deviation at apex (mm) Angular deviation ( )
BLT GSM 0.825 ± 0.167 0.974 ± 0.14 2.747 ± 0.306
GPA 0.713 ± 0.092 0.891 ± 0.179 3.62 ± 0.275
TL GSM 1.073 ± 0.181 1.328 ± 0.226 3.656 ± 0.538
GPA 1.225 ± 0.359 1.193 ± 0.305 4.319 ± 0.642
BL GSM 1.203 ± 0.106 1.352 ± 0.192 3.614 ± 0.497
GPA 1.132 ± 0.201 1.282 ± 0.281 3.876 ± 0.232

Abbreviations: GPA, guided portable adapter; GSM, guided Screwed-in mount.

EL KHOLY ET AL.
3 | RESULTS
The results of the multivariate analysis (Table 1) showed no significant
interaction between the combinations of implant macrodesign and
insertion device in any of the measurement categories. Therefore,
direct comparisons between different insertion device groups and
implant macrodesigns groups were performed.
3.1 | Effect of macrodesign on accuracy of sCAIS
Result analysis of different implant macrodesigns (Table 2 and Figure 5)
revealed that BLT implants had lower mean 3D deviation values at the
crest and the apex, when compared with 3D deviations with BL and TL
implants. These differences were statistically significant (P = .017 at
crest and P = .033 at apex). BLT implants had also lower angular devia-
tions, when compared with BL and TL Implants. However, angular devi-
ation differences were not statistically significant.
3.2 | Effect of the insertion device on sCAIS
The effects of the insertion device are summarized in Figure 6 and
Table 2. No significant differences were noted between insertion
devices in 3D deviation or angular deviation values.
FIGURE 5 The effect of the implant macrodesign on the 3D deviation and angular deviation. TL, tissue level; BL, bone level; BLT, bone level tapered
F I G U R E 6 The effect of the guided insertion device on the 3D deviation and angular deviation. GPA, guided portable adapter; GSM, guided
Screwed-in mount
5
4 | DISCUSSION
Previous studies found that fully guided implant surgeries (guided dril-
ling and guided implant placement) provide superior accuracy, than
partially guided systems.2,3,6-8,10,19 This in vitro investigation focused
on the influence of the macrodesign of the implant and the insertion
device used for implant placement on positional accuracy when using
sCAIS. The choice of a non-clinical model was based on the principal
that isolating technology variables is better scientifically accomplished
through in vitro research models than clinical studies. One can ques-
tion the appropriateness of using a clinical model, to investigate basic
technology variables.
The results of the present investigation confirm that both tested
insertion devices yielded acceptable results in sCAIS protocols. Cur-
rently, implants are available in guided and nonguided variations.
Guided implants are supplied from the manufacturer attached to a
GSM specifically for sCAIS placement. However, a GPA was intro-
duced, that can be mounted onto the standard transfer piece (Loxim)
of a standard nonguided implant and used for sCAIS. The above
results are evidence that implants could be placed with similar accu-
racy with use of either insertion device, and therefore clinicians can
benefit from the flexibility offered by using the portable guided adap-
tor with a standard (stock) Loxim mount.
6 EL KHOLY ET AL.
To the best of the authors' knowledge, no studies in the existing
literature have evaluated the influence of the implant macrodesign on
the accuracy of sCAIS procedures. The finding that deviation values
associated with BLT implants were significantly lower than BL and TL
implants was a significant and novel one. A possible explanation might
be differences in drill designs. The drills for TL and BL implants are
straight twist drills, while the BLT drills, except the pilot drill, are verti-
cally fluted tapered drills. It is plausible that the drill design, that is,
straight or tapered geometry and its sharpness has an influence on
the accuracy of the osteotomy and hence an influence on the devia-
tion.10 Drill-engineering literature has indeed reported that drill design
influences accuracy of the drilling process.22-24 The straight flute drills
for tapered implants create a slightly narrower osteotomy at the apex
as compared to the twist drills that create an almost parallel walled
osteotomy. Additionally, TL and BL implants, when placed into a pre-
pared osteotomy the implants make immediate contact with the oste-
otomy walls due to their parallel design. In contrast, the BLT implants
make initial contact with the implant osteotomy only after the tapered
5 mm apical portion is subcrestal. Theoretically, the non-self-cutting
threads of the TL implants follow the path of least resistance (ie, the
prepared osteotomy). Consequently, there is an increased tendency
for the implant to enter the crestal half of the osteotomy more pas-
sively. The apical 5 mm of the BLT is self-cutting and these aggressive
threads may allow cutting/expansion of the bone. Indeed, previous
studies stated that sharp self-tapping implants reduce inaccuracies of
deviations into path of least of resistance in extraction sockets and
dense sites.25 This may result in better positional accuracy as com-
pared to the TL designs, but does not explain the difference between
TL and BL implants.
Based on drill mechanics literature, when a drill rotates in a mate-
rial it creates a self-excited vibration (chatter). These vibrations often
alter dimensional accuracy of the drilling process by altering hole and
bore geometry.26 These dimensional inaccuracies of the osteotomy
could be translated into inaccuracies in implant position. In general, it
can be stated that the number of clinical complications with s-CAIS
seems to be negligible and comparable to conventional implant
surgeries.5
Data from clinical trials analyzed in a meta-analysis by Tahmaseb
et al indicated that sCAIS can be used to realize virtual planning posi-
tions with reasonable accuracy, however, considerable errors can be
present. These errors can be of a magnitude that influences the final
esthetic outcome, the safety of the surrounding soft tissues, or even
changing the overall final prosthetic plan.17 The same research group
suggested in a 2014 systematic review27 that deviation values calcu-
lated after only drilling the osteotomy can be significantly different if
measured after implants are placed. Hence, the dimensional inaccura-
cies can be attributed to the drill or to the implant macrodesign or to
both. However, further research in this area is recommended.
In conclusion, the macrodesign of dental implants influences the
accuracy of sCAIS, with tapered designs offering statistically signifi-
cant positional accuracy than parallel-walled macrodesigns. An expla-
nation might be related to the drill design, the thread design, and/or
the insertion geometry.
CONFLIC T OF INT ER E ST
None.
OR CID
Karim El Kholy https://orcid.org/0000-0002-6426-1774
Julia-Gabriela Wittneben https://orcid.org/0000-0003-0778-2298
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How to cite this article: El Kholy K, Ebenezer S,
Wittneben J-G, Lazarin R, Rousson D, Buser D. Influence of
implant macrodesign and insertion connection technology on
the accuracy of static computer-assisted implant surgery. Clin
Implant Dent Relat Res. 2019;1–7. https://doi.org/10.1111/
cid.12836